Henry Rosevear, MD, discusses his experience with the On-Demand Course Pass for this year’s AUA annual meeting, including the two On-Demand courses he found most informative.
As part of my virtual AUA conference experiment this year, I purchased the On-Demand Course Pass. I knew that I wouldn't have the chance to attend many, if any, of the instructional courses and given how much I learned from them the last time around, I figured that the $197 investment was worth it.
And really, $197? What a steal-my hotel room in Boston was more than that.
My conclusion? With the exception that it took longer than I expected for the AUA to get the videos posted and available, they were great. Almost too great. Unless I need the CME credit for some reason (you don't get credit for watching videos of the courses from the comfort of your own home), I don't think I'll purchase the in-person course pass again. Why spend time listening live if I can watch the videos at home at 2x speed?
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The other problem I have with the On-Demand course is that there are so many great lectures that I can't possibly do them all justice (even given the unlimited word count my editor gives me for this online blog). Instead, I want to highlight the two courses I found most useful.
The first course was “Prostate Cancer Diagnostics: Biomarkers, MRI, and Biopsy Techniques,” directed by Daniel Barocas, MD.
I found this course helpful since Dr. Barocas not only talked about current prostate cancer biomarkers, but he gave a great overview of the current state of prostate MRI. He started by stating that prostate MRI should not (yet) be used to avoid a systematic biopsy in a man with a suspicious lesion. It should also not be used to avoid doing a prostate biopsy in a highly suspicious man with a normal prostate MRI. I'll admit that I was doing the opposite in both of those situations.
I was also thrilled to see that he pointed out that it is a NCCN guideline that all men with a rising PSA after a negative biopsy receive an MRI; this factoid will help me defend my ordering practices the next time I have to go head to head with some insurance peer-review lackey. Interestingly, he also pointed out that the NCCN guideline’s fine print says "emerging data" suggests that MRI before initial biopsy is helpful; I look forward to that becoming standard of care.
Dr. Barocas also addressed one of my key questions at AUA 2017; do I need to buy a $250,000 MRI-US fusion device?
He said: "There are some studies here at the AUA showing that freehand cognitive fusion may be just as good in many cases.” Interestingly, he also stated that the positive predictive value (PPV) of MRI is 60% for PI-RADS 3, 90% for PI-RADS 4, and 96% for PI-RADS 5. I think this stresses the importance of a quality assurance system in any group that routinely uses this technology, as a quick review of my own last 10 cases does not correlate with these data, meaning that either I or my radiologist is not doing something right.
So to partially answer my question, it appears that MRI technology is ready for prime time, and all small-town urologists should start incorporating prostate MRIs in our diagnostic algorithms. On the other hand, the value that the $250,000 MRI-US fusion technology adds is less clear. I believe that if a group can match the published data regarding PPV using cognitive fusion biopsies, than the need for the machine is probably minimal.
Next: “The Role of Sacral Neuromodulation in Urological Practice.”
The other On-Demand Course that I wanted to highlight is “The Role of Sacral Neuromodulation in Urological Practice.” I've written about the use of clinical pathways and how they apply to OAB in the past, and this course by Steven Siegel, MD, does a wonderful job of teaching how this particular aspect of the clinical pathway for OAB works. And don't underestimate clinical pathways!
Dr. Siegel's fifth slide showed his own clinical pathway for OAB. All groups should have a pathway that is followed and ideally, though I'll concede my group is not yet doing this, is monitored for compliance by all providers.
Why is neuromodulation so important? First remember that OAB is a real disease that has significant impact on our patient's quality of life and, according to one slide, only 15% of patients are still on medications for OAB at their 1-year anniversary.
Does sacral nerve modulation work? Absolutely! Dr. Siegel's data, which is broadly supported in the literature, shows a significant improvement in symptoms with few complications (60%-77% success depending on which study you read). This, like all surgeries, is very operator dependent, and the exact position of the lead matters. While I left residency thinking that I was well trained in this operation, when I joined my group, I learned we had an excellent implantor and, as a result, all of my patients are sent to him for evaluation. He tends to send me robotic cases, so we're both happy and I'm also confident our patients get better outcomes too.
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Dr. Siegel also reminded viewers that percutaneous tibial nerve stimulation works well and has been proven in a well-designed sham study. Overall, neuromodulation for the treatment of OAB in the appropriate patient as guided by clinical pathways is a prime-time technique that all of us small-town urologists should be offering our patients.
As I mentioned earlier, there are numerous other fantastic courses available through the On-Demand Course Pass. My three honorable mentions include: “Nocturia: Advances in Diagnosis and Management” (talk about a symptom I see on a daily basis!), “Nutrition Counseling for the Prevention of Urolithiasis” (great summary of dietary ways to minimize stone prevention), and “Active Surveillance for Prostate Cancer” (a great algorithm to ensure I am appropriately following these patients).
I hope everyone not only enjoyed Boston as much as I did, but also left the meeting a smarter and better urologist. For those that didn't have the chance to attend, the AUA's On-Demand course is a wonderful, cheap, and easy-to-use alternative to educate yourself on the latest updates in urology.
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